Basic Research—Technology

Debris Removal from the Mesial Root Canal

System of Mandibular Molars with
Laser-activated Irrigation
Stamatina Passalidou, DDS, MSc, Filip Calberson, DDS, MSc, Mieke De Bruyne, DDS, MSc, PhD,
Roeland De Moor, DDS, MSc, PhD, and Maarten August Meire, DDS, MSc, PhD

Abstract
Introduction: The purpose of this study was to compare
in vitro the canal and isthmus debridement of manual-
dynamic, passive ultrasonic, and laser-activated irrigation
I rrigation of the root ca-
nal with antimicrobial
solutions is paramount to
Significance
Many irrigant activation techniques have been
described, with great variation in the working
with an Er:YAG laser in mesial roots of human mandibular thorough cleaning and
mechanism and efficacy. This study found all
molars. Methods: Fifty extracted mandibular molars with disinfection of the root ca-
tested activation methods to aid in debriding the
an isthmus were embedded in resin and sectioned axially nal system. The irrigants
mesial root canals of mandibular molars.
4 mm from the apex. The teeth were reassembled with flush away debris, clean
guide pins and bolts, and the mesial canals were the noninstrumented
instrumented up to a ProTaper F2 rotary file (Dentsply areas of the root canals, remove the smear layer, and disinfect the canal space (1–
Maillefer, Ballaigues, Switzerland). Teeth were randomly 3). The traditional syringe needle method of irrigation often fails in adequate
assigned to the following irrigant activation groups delivery and penetration of irrigant solutions within the complex 3-dimensional micro-
(n = 10): conventional needle irrigation (NI), manual- structure of the canal system because the fluid penetration in the apical third and
dynamic irrigation with a ProTaper F2 gutta-percha beyond the main canal is limited (4). Therefore, irrigant activation techniques have
cone, ultrasonically activated irrigation using a size been suggested to improve their distribution in the canal system and increase irrigation
20 Irrisafe (Satelec Acteon, Merignac, France), and effectiveness (5).
laser-activated irrigation (LAI) with an Er:YAG laser and An isthmus is a challenging area to debride because of its confined dimensions,
a conical 400-mm fiber tip in the canal entrance or a deep extension, and frequent clogging with hard and soft tissue debris during instru-
600-mm tip over the canal entrance. Root cross-sectional mentation with rotary NiTi instruments (6). This may result in remaining pulpal tissue,
images were taken before and after final irrigation, and debris, or microorganisms, yielding potential for treatment failure (7). The incidence of
the area occupied by debris in the main canal and the an isthmus is high (54.8%) in the mesial root of mandibular molars, particularly in
isthmus was determined using image analysis software. sections 3–5 mm from the apex (8, 9).
Differences in debris before and after activation were Different irrigant activation techniques have been proposed. Manual dynamic irri-
statistically compared within and across groups. Results: gation (MDI) involves the vertical movement of a well-fitting gutta percha within the in-
Significant reductions in debris levels were observed in all strumented canal, improving displacement and exchange of irrigant. MDI has been
groups, except for NI and manual-dynamic irrigation proven to result in better root canal cleaning than conventional needle irrigation
(canal only). None of the methods rendered the canal (NI) and is considered simple and cost-effective (10, 11). Ultrasonically activated
systems debris free. In the canal, LAI with an Er:YAG laser irrigation (UAI) implies the activation of irrigant by a noncutting, ultrasonically
and a 600-mm tip over the canal entrance removed oscillating instrument placed in the center of the canal after its shaping (12). Although
significantly more debris than NI. In the isthmus, LAI cavitation effects have been observed with UAI (13), its main cleaning action is attrib-
with an Er:YAG laser and a conical 400-mm fiber tip in uted to acoustic microstreaming. UAI has been shown to be more effective than conven-
the canal entrance removed significantly more debris tional irrigation in cleaning root canal extensions (14). Some studies have specifically
than NI. Conclusions: Within the limitations of this shown a significantly cleaner isthmus when UAI is used in comparison with syringe irri-
in vitro study, canal and isthmus cleanliness significantly gation (15).
improved after irrigant activation. (J Endod 2018;-:1–5) Laser-activated irrigation (LAI) is another method of irrigant activation. With LAI,
the tip of an erbium laser is activated within a canal brim full of irrigant. The effect of LAI
Key Words is based solely on cavitation. The radiation emitted by erbium lasers is strongly ab-
Er:YAG laser, isthmus, laser-activated irrigation, PIPS, sorbed by water or water-based root canal irrigants (16). Pulsed laser operation results
root canal irrigation, ultrasonically activated irrigation in expanding and imploding vapor bubbles at the fiber tip, resulting in considerable

From the Department of Restorative Dentistry and Endodontology, Dental School, Ghent, Belgium.
Address requests for reprints to Dr Roeland De Moor, Department of Restorative Dentistry and Endodontology, Dental School, Ghent University, Ghent University
Hospital, De Pintelaan 185/P8, B-9000 Ghent, Belgium. E-mail address: [email protected]
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.06.007

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Basic Research—Technology

Figure 1. Specimen preparation. (A) A mandibular molar with an isthmus based on cone-beam computed tomographic imaging. (B) The specimen embedded in
resin. (C) The specimen after the placement of bolts and guide pins in predrilled shafts. (D) The specimen after sectioning and reconstruction.

fluid movement inside the canal (17), shock waves in the fluid at the then sealed with flowable composite resin (Filtek Supreme; 3M ESPE,
point of collapse (18), and secondary cavitation that can cause acoustic St Paul, MN). Each tooth was then embedded in transparent resin (Or-
streaming. In the photon-induced photoacoustic streaming approach, a thocryl; Dentaurum BVBA, Antwerp, Belgium), resulting in cubical
conical fiber tip on a pulsed Er:YAG laser is used with low pulse energies specimens with 25-mm edges. Four cylindrical holes were drilled in
(10 or 20 mJ) and a very short pulse length (50 microseconds), result- the resin, parallel to the long axis of the tooth.
ing in high peak powers and hence more efficient cavitation generation. The blocks were then sectioned axially at 4 mm from the apex us-
Although the fiber tip originally was held in the canal entrance, the tip ing a low-speed saw (Isomet; Buehler, Dusseldorf, Germany). Stan-
position has been changed to the pulp chamber. dardized high-resolution images of the coronal surface of the apical
It is currently unclear which LAI approach better cleans the section were then taken using a digital single-lens reflex camera (Nikon
isthmus and how LAI compares with UAI in canal and isthmus debride- D300; Nikon Corp, Tokyo, Japan) with a macrolens (Medical Nikkor
ment. Therefore, the aim of the present study was to compare in vitro 120 mm f/4.0, Nikon Corp) mounted on a platform with an adjustable
the canal and isthmus debridement of syringe irrigation, MDI, UAI, and stage for positioning of the sections. The slices were reassembled and
2 LAI approaches. fixated with the help of guide pins and metal bolts in the predrilled shafts
(Fig. 1A–D).
Methods
Tooth Selection Canal Preparation
Extracted human mandibular molars were subjected to cone- The mesial roots were then prepared with rotary instruments
beam computed tomographic imaging (Promax 3D; Planmeca, Hel- (ProTaper Universal) up to a ProTaper F2 file. The instrument sequence
sinki, Finland), in order to explore the presence of an isthmus in the was S1, S2, F1, and F2. The canals were rinsed with 1 mL sodium hy-
mesial root. All the teeth had completed root formation and had been pochlorite (NaOCl) 2.5% after each file using a 3-mL syringe and a
extracted for reasons unrelated to the current study. The sample collec- 27-G needle (Monoject; Tyco Healthcare, Mansfield, MA). After drying
tion and study methodology were approved by the institutional ethics with paper points, the specimens were disassembled, and images of the
committee (project no. EC/2018/0543). Tooth imaging continued until coronal surface of each section were taken as described previously.
50 teeth with an isthmus were identified. These images comprised the postpreparation images.

Final Irrigation
Specimen Preparation
Teeth were then randomly assigned to 1 of 5 groups (n = 10) rep-
The experimental setup is a modification of the protocol as
resenting different irrigant activation methods:
described by Klyn et al (19). After standard access cavity preparation,
cusps were flattened to obtain stable reference points. Coronal interfer- 1. Conventional NI with 4 mL 2.5% NaOCl using a 27-G endodontic nee-
ences in both mesial canals were removed with ProTaper Universal Sx dle (Monoject). The needle was moved up and down in the canal
and S1 instruments (Dentsply Maillefer, Ballaigues, Switzerland). Then, with a flow rate of approximately 0.3 mL/s.
the working length was established by subtracting 1 mm from the length 2. MDI: a ProTaper F2 gutta-percha cone was inserted to the working
at which the tip of an ISO10 file was just visible at the apical foramen. A length. A total of 100 push-pull strokes were performed manually
glide path was made with an ISO 15 K-file. The apex of each root was in 1 minute. The canal was then irrigated with 4 mL 2.5% NaOCl

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 Basic Research—Technology
using a 30-G irrigating needle (Appli-Vac; Vista Dental Products, entrance. The remainder was identical to that performed in the
Racine, WI). LAI400 group.
3. UAI: a noncutting #20 file (Irrisafe; Satelec Acteon, Merignac,
The root canals were dried with paper points, and images of the
France) driven by an ultrasonic device (Suprasson Pmax Newtron,
sections were taken as described previously.
Satelec Acteon) was used in the canal for 3  20 seconds at 50%
power. The file was prebent to allow insertion up to the working
length minus 1 mm. In between each 20-second cycle, the canal Evaluation Method
was rinsed with 1 mL NaOCl and finally with 2 mL. Each picture was analyzed using imaging software (SigmaScan
4. LAI400: a 2.940-nm Er:YAG laser (AT Fidelis; Fotona, Ljubljana, Pro; Systat Software, San Jose, CA, and Adobe Photoshop CS5; Adobe
Slovenia) equipped with a handpiece (R14-PIPS, Fotona) holding Systems Inc, San Jose, CA). The outline of the root canal and the isthmus
a conical 400-mm-diameter fiber (XPulse 400/14, Fotona) was was traced as well as the area occupied by debris within the canal or
used to activate the irrigant. The fiber tip was placed in the canal within the isthmus. These areas were quantified by counting the number
entrance and activated for 3  20 seconds. The pulse energy was of pixels. The debris percentage was calculated as the ratio between the
20 mJ, the frequency was 20 Hz, and the pulse length was 50 micro- debris area and the total canal or isthmus area. The debris difference
seconds. In between each 20-second cycle, the canal was rinsed with was defined as debris percentage before activation minus debris per-
1 mL NaOCl and finally with 2 mL. centage after activation. Statistical analysis was performed using SPSS
5. LAI600: the same laser and handpiece were used to hold a conical Statistics Version 23.0 (IBM, Armonk, USA). One-way analysis of vari-
600-mm-diameter fiber (XPulse 600/14; Fotona). This time the tip ance (ANOVA) was used to compare the debris differences across the
of the fiber was placed in the pulp chamber over the canal different activation groups. Because the debris percentages before

Figure 2. Representative images of the sections showing canals and isthmuses (A) before instrumentation, (B) after instrumentation, and (C) after irrigant acti-
vation with a (1) 27-G needle, (2) MDI, (3) UAI, (4) LAI400, and (5) LAI600.

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Basic Research—Technology
TABLE 1. The Mean Debris Percentages (Standard Deviation) in the Canal Discussion
Area before and after Irrigant Activation (n = 10) This study sought to quantify debris removal using different final
Mean Mean irrigation protocols from both the canals and isthmus of mesial roots
Group debris % pre debris % post Difference (%) of mandibular molars. The model that was used in this study was based
NI 22.5 (16.4) 18.9 (11.4) 3.6 (12.4)a on the K-Kube described by Klyn et al (19). The combination of guide
MDI 27.0 (12.9) 17.4 (9.5) 9.6 (18.6)a,b pins and tightening bolts provided the necessary repositioning precision
LAI400 24.7 (13.7) 5.7 (8.1)* 19.1 (12.8)a,b and compressive force to the tooth slices, allowing investigation of root
LAI600 29.6 (20.5) 3.3 (4.5)* 26.3 (18.5)b cross sections at the different stages of root canal preparation and irri-
UAI 26.4 (13.6) 5.5 (5.9)* 20.9 (13.1)a,b
gation. Although the K-Kube requires cutting of the tooth specimen, it
LAI400, laser-activated irrigation with a conical 400-mm fiber tip in the canal entrance; LAI600, laser- offers the advantage of evaluating both hard and soft tissue debris, which
activated irrigation with a 600-mm tip over the canal entrance; MDI, manual dynamic irrigation; NI, is not possible with (nondestructive) micro–computed tomographic
needle irrigation; UAI, ultrasonic-activated irrigation. analysis. This model also provides a closed system, a prerequisite to
Different superscript letters indicate significant debris differences between groups.
study irrigation protocols (20).
*A significant difference in debris percentage before and after activation.
When comparing debris levels before and after activation, UAI and
and after irrigant activation were not normally distributed in all groups, LAI resulted in significantly improved cleaning in the canal area
the Wilcoxon test was used to compare these data across the groups. compared with syringe irrigation and MDI. In the isthmus area,
The significance level was set at .05. improved canal cleaning was determined in all activation groups. The
results of this study indicate that after chemomechanical canal prepara-
tion, additional canal system debridement can be obtained with activa-
Results tion techniques, confirming the role of these additional activation steps.
The presence of an isthmus was confirmed in all specimens. In the present study, the differences between the experimental
Before activation, mean debris levels in the isthmus (60.3%) were groups were not statistically significant. The only significant differences
significantly higher than those in the canal (26.0%). Representative sec- were between the LAI and the control (NI) groups. When considering
tion images from all groups are shown in Figure 2A–C. the present results, the great variation in the preoperative debris per-
centages is notable. These great deviations could explain the lack of sig-
Main Canal nificant differences between groups. The debris score variations were
Table 1 shows the mean debris percentages in the canal before and especially in the isthmi, a finding also confirmed in other studies
after irrigant activation in the different groups. No significant differences (19, 21). This variation in preoperative debris levels can have to do
in debris percentage before activation were observed between groups with the presence or absence of an (intact) pulp at the beginning of
(P > .05). When comparing debris levels before and after activation, the experiment, with the soft pulp tissue facilitating accumulation of
statistically significant differences were noted in the UAI, LAI 400, and hard tissue debris in canal extensions/isthmi in comparison with a
LAI600 groups (Wilcoxon test, P < .05) but not the NI and MDI groups pulpless tooth. Root canal system anatomy can also play a role, with
(P > .05). Statistically significant differences in debris difference were a wide isthmus and a limited intercanal distance acting as factors
observed only between NI and LAI600 (1-way analysis of variance, post promoting flushing of debris. No attempts were made to control
hoc Tukey test, P > .05). these factors in the present study.
The degree of debris reduction with LAI in both the canal and
Isthmus isthmus area is in accordance with previous in vitro studies in which
Table 2 shows the mean debris percentages in the isthmus before LAI with erbium lasers has been shown to be more effective than
and after irrigant activation in the different groups. No significant differ- syringe/needle-based irrigation in terms of debris removal from artifi-
ences in isthmus debris percentage before activation were observed be- cial root canal irregularities (22–25). No statistically significant
tween groups (ANOVA, P > .05). When comparing debris levels before differences in debris removal between LAI or UAI were obtained in
and after activation, statistically significant differences were noted in all the present study, neither for the canal nor the isthmus area. Other
groups (Wilcoxon test, P < .05). Statistically significant differences in studies comparing LAI with UAI in isthmi, canal extensions, or
debris difference were observed only between NI and LAI400 (1-way irregularities came to a similar conclusion (24, 26). However, other
ANOVA, post hoc Games-Howell test, P < .05). investigations found LAI to be significantly better than UAI in
removing dentinal debris in an artificial groove in the canal wall (25,
27).
TABLE 2. The Mean Debris Percentages (Standard Deviation) in the Isthmus The lasing conditions of the 50-microsecond pulse duration, the
Area before and after Irrigant Activation (n = 10) 20-mJ pulse energy, and conical fiber tip delivery, as used in this exper-
iment, represent the photon-induced photo acoustic streaming
Mean Mean
Group debris % pre debris % post Difference (%) approach. In this approach, the combination of a conical tip and
very short pulses produce profound irrigant dynamics, whereas the
NI 53.3 (36.3) 34.6 (23.8)* 18.7 (16.6)a low pulse energy produces minimal thermal effects (18, 28). When
MDI 58.0 (28.3) 31.3 (23.5)* 26.8 (26.8)a,b
LAI 400 65.2 (26.1) 6.4 (7.9)* 58.8 (25.9)b comparing the 2 LAI protocols, no statistically significant differences
LAI 600 62.8 (36.6) 15.9 (30.8)* 46.9 (43.5)a,b were observed. More studies are needed to compare the efficacy of
UAI 62.1 (25.3) 34.7 (29.4)* 27.4 (23.1)a,b LAI with these 2 approaches.
LAI400, laser-activated irrigation with a conical 400-mm fiber tip in the canal entrance; LAI600, laser-
In the main canals, MDI did not result in a significant reduction in
activated irrigation with a 600-mm tip over the canal entrance; MDI, manual dynamic irrigation; NI, debris level, whereas in the isthmus debris reduction was significant.
needle irrigation; UAI, ultrasonic-activated irrigation. These results suggest that MDI works better when a lateral “escape
Different superscript letters indicate significant debris differences between groups. way” for the debris is available, which is the case in an (open) isthmus,
*A significant difference in debris percentage before and after activation. and not in a dead-ending canal extension. Both Susin et al (29) and

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Parente et al (30) hypothesized that the irrigant displacement could be 11. Jiang LM, Lak B, Eijsvogels LM, et al. Comparison of the cleaning efficacy of different
hindered by a relatively close adaptation of the gutta-percha cone to the final irrigation techniques. J Endod 2012;38:838–41.
12. van der Sluis LW, Versluis M, Wu MK, et al. Passive ultrasonic irrigation of the root
canal wall, resulting in the debris settling back into the canal system af- canal: a review of the literature. Int Endod J 2007;40:415–26.
ter removal of the gutta-percha cone. 13. Macedo RG, Verhaagen B, Fernandez Rivas D, et al. Sonochemical and high-speed
In the present study, the greatest debris reductions were obtained optical characterization of cavitation generated by an ultrasonically oscillating dental
with the LAI protocols. However, these results were not significantly file in root canal models. Ultrason Sonochem 2014;21:324–35.
different from the other activation groups, probably because of great 14. Jiang LM, Verhaagen B, Versluis M, et al. The influence of the ultrasonic intensity on
the cleaning efficacy of passive ultrasonic irrigation. J Endod 2011;37:688–92.
variation in preoperative debris levels. Nevertheless, in many studies 15. Gutarts R, Nusstein J, Reader A, et al. In vivo debridement efficacy of ultrasonic irri-
involving LAI, LAI cleaning results were either better than those of gation following hand-rotary instrumentation in human mandibular molars. J Endod
UAI or other activation techniques (23–25, 27); or the results did 2005;31:166–70.
not differ significantly from these groups, while net outcome were 16. Meire MA, Poelman D, De Moor RJ. Optical properties of root canal irrigants in the
300-3,000-nm wavelength region. Lasers Med Sci 2014;29:1557–62.
better (26). This trend suggests LAI possesses a stronger activation ac- 17. Blanken J, De Moor RJ, Meire M, et al. Laser induced explosive vapor and cavitation
tion. It is hypothesized that this is because of the violent fluid dynamics resulting in effective irrigation of the root canal. Part 1: a visualization study. Lasers
caused by the expanding and imploding bubbles at the fiber tip of the Surg Med 2009;41:514–9.
Er:YAG laser. This physical process appears to be more vigorous than 18. Gregorcic P, Jezersek M, Mozina J. Optodynamic energy-conversion efficiency dur-
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Within the limitations of this in vitro study, it can be concluded that ca- 19. Klyn SL, Kirkpatrick TC, Rutledge RE. In vitro comparisons of debris removal of the
nal and isthmus cleanliness significantly improved after the final irriga- EndoActivator system, the F file, ultrasonic irrigation, and NaOCl irrigation alone af-
tion regimen in each group. ter hand-rotary instrumentation in human mandibular molars. J Endod 2010;36:
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Acknowledgments using a side-vented needle for positive-pressure irrigant delivery. J Endod 2010;36:
The authors deny any conflicts of interest related to this study. 745–50.
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